mm disorders and tx pt one Flashcards
Musculoskeletal Disorders
which are centrally maintained
- Myofascial Pain Syndrome (MFPS)- Centrally Maintained
Pain - Myalgia
- Fibromyalgia- Centrally Maintained Pain
- Spasm
- Myositis
mc Musculoskeletal Disorder
myalgia
which Musculoskeletal Disorder is tx by rheumatologist
fibromyalgia
main tx modality for musculoskeltal dx
PT
spasms can follow?
trauma/bruxism
myostitis can follow
trauma/infection
Mechanisms that produce Pain for Masticatory skeletal muscles
Myofascial Pain Syndrome characterized by?
Characterized by the presence of Trigger Points (TPs) in any voluntary muscle which cause referred pain and referred tenderness and may be active or latent up palpation/function.
TPs evoke?
TPs evoke referred pain which usually originates from a distant site
rather than the site of the pain complaint.
ACTIVE TPs
ACTIVE TPs: are painful to palpation or spontaneously produce local pain OR refer pain and autonomic symptoms (i.e. erythema) to remote areas in reproducible patterns characteristic of each muscle
LATENT TPs
could occur with?
LATENT TPs: exhibit local tenderness but do not currently cause
spontaneous clinical pain or symptoms.
could occur with previous trauma that was not adressed
Myofascial Trigger Point
DEFINITION:
pain sensation described?
An irritable locus within a taut band of skeletal muscle or fascia which when stimulated elicits referred pain & tenderness (“secondary hyperalgesia- increased sensitivity to normally painful stimuli outside & surrounding a zone of primary hyperalgesia”). (1)
Referred pain from myofascial trigger points is dull and aching, usually deep, and can range from discomfort to incapacitating pain.
1/2 nn interconnect which can allow pain to cross CN distributions (5/11
Muscle Palpation Examination
Remember that the pain location ?
Palpate which muscles with mouth open
Muscle Palpation Examination
Remember that the pain location MAY not be the source of pain
Palpate the Masseter and Temporalis muscles with mouth open
Myofascial Pain Syndrome (MFPS)
May be found in what mm?
mediation?
May be found in any voluntary muscle
Is a Centrally Mediated Pain. Fields (4) described a means where the CNS may switch on Nociception by stimulating the “on” cells which causes activation of the Trigeminal Nucleus nociceptors
Myofascial Pain Syndrome, chronic?
Is chronic, continuous muscle pain (myalgia) that is aggravated by function and refers pain beyond the boundary of the masticatory muscle being palpated
Nociception:
Nociception: “stimulation of specialized nerve endings designed to transmit
information to the central nervous system concerning potential or actual tissue
damage
Nociceptor:
Nociceptor: “a specialized nerve ending that senses painful or harmful sensations”
(i.e. a primary afferent nerve)
Myofascial Pain diagnosis difficulty, why?
scm refferal patterns
Myofascial Pain
The most elusive and difficult to diagnose since it refers
pain to other locations in the mouth and in the face and
head & does Not always follow Cranial Nerve Distributions-
(CN XI with active SCM trigger point refers to CN V in face
and head)
Myofascial Pain
Diagnostic Criteria: (must be present):
pain type? aggrevated by?
tps?
> 50% pain reduction occurs with?
Regional dull, aching pain aggravated by mandibular function when muscles of mastication are involved.
Trigger points have a characteristic pattern of pain referral & alters the pain complaint on palpation or spontaneously.
> 50% pain reduction occurs with vapocoolant spray or local anesthetic injection (trigger point injection) using 1% Procaine without vasoconstrictor.
Myofascial Pain
May be accompanied by:
Muscle?
Sensation of?
Ear? teeth? HA?
ROM?
pain in referal region
Muscle stiffness
Sensation of acute malocclusion not verified clinically.
Ear Symptoms, tinnitus, vertigo, toothache, tension-type headache.
Decreased mouth opening (if masticatory muscles involved).
Hyperalgesia in region of referred pain.
Pathophysiology of Masticatory Myofascial Pain
understood?
1. thresholds?
2. what may cause increased nociception which causes pain sensitivity?
3. CNS?
Not fully understood
1. Suspect lower pain thresholds in these individuals
2. Estrogen and nerve growth factor (NGF) may cause increased nociception which causes pain sensitivity
3. Hyperexcitability in CNS & upregulation of nociceptive processing (decreased inhibition of pain)
TMJ & Ear Pain:
Referred by which mm:
MASSETER (deep)
LATERAL PTERYGOID
MEDIAL PTERYGOID
STERNOCLEIDOMASTOID (clavicular
Toothache:
Referred by which mm:
TEMPORALIS
MASSETER (superficial)
DIGASTRIC (anterior)
masetter referal patterns
temporalis refferal patterns
digastric and medial pterygoid refferal patterns
Lateral Pterygoid Referral pattern
SCM refferal
Myofascial Pain
May be?
Avoid what txs?
Myofascial Pain
May be transient and self-limiting, resolving without serious long-term
effects.
Avoid irreversible treatments (i.e. occlusal adjustments)
Myalgia
Diagnostic Criteria: (must be present)
1. Muscle pain reported by patient in ?
2. Pain is aggravated by?
3. Muscle palpation exam causes?
- Muscle pain reported by patient in the jaw, temple, ear or pre-auricular area in the last 30 days
- Pain is aggravated by jaw movement or parafunction (i.e. bruxism)
- Muscle palpation exam causes report of localized muscle pain at palpation site
what may be present with myalgia
Limited range of mouth opening MAY be present
myalgia is secondary to?
Ischemia
Bruxism
Fatigue
Metabolic alterations
Delayed onset muscle soreness from overuse
Protective splinting
Myositis
Diagnostic Criteria must be present:
1. pain following?
2. tissue app?
- Local muscle pain following injury (non-infective) or infection (infective)
- Edema, erythema, &/or increased temperature over the muscle
myostitis may be present:
1. Serologic tests may reveal?
2. tender?
3. Increased pain with?
4. ROM
- Serologic tests may reveal elevated enzyme levels (i.e. creatine kinase), markers
of inflammation & the presence of an autoimmune disease. - Diffuse tenderness over the entire muscle.
- Increased pain with jaw use if masticatory muscles involved.
- Limited range of motion of unassisted mandibular movements secondary to pain
Myospasm
Diagnostic criteria Must be present:
1. pain with?
2. ROM?
3. contractions?
4. EMG will Confirm?
- Acute onset of pain at rest & with function.
- Immediate report of limited range of jaw motion <40mm for vertical opening
- Continuous involuntary muscle contraction
- EMG will Confirm elevated electromyographic activity compared to the
contralateral unaffected muscle.
myospasm may be present:
Acute Malocclusion
Myospasm
Also known as?
occurence? typical cause?
Difficult to differentiate between?
1st line tx
Myospasm
Also known as “trismus” or “cramp”.
Occurs relatively infrequently in orofacial pain population & typically is caused
by trauma.
Difficult to differentiate between disc displacement without reduction
clinically when limited unassisted vertical range of mouth opening is <40mm.
tx with PT
Contracture
defined?
pain?
History of ?
Contracture
Shortening of a muscle due to fibrosis of tendons, ligaments, or
muscle fibers
Usually not painful unless muscle is overextended
History of radiation therapy, trauma, or infection is often present
Contracture
Diagnostic Criteria MUST be present:
1.ROM?
- Progressive loss of range of motion with unassisted and assisted
opening < 40mm causing a “hard end feel”
Fibromyalgia Pathophysiology:
understood? beleieved to involve?
little evidence of ?
may involve dysfunction of?
is poorly understood but believed to involve a central sensitivity syndrome
little evidence of peripheral tissue abnormalities
may involve dysfunction of autonomic nervous system
Associated Co-morbid Medical disorders of fibromyalgia
TMD (10% of population)
Inflammatory & neuroendocrine disorders
IBS, functional chest pain from esophageal origin
Chronic pelvic pain
Headaches especially Migraines
FIBROMYALGIA
Diagnostic Criteria MUST be present:
1. Tenderness on palpation ?
2. Presence of?
3. Pain is?
- Tenderness on palpation of at least 11 of 18 specified sites
- Presence of wide-spread pain with concurrent masticatory muscle pain
- Pain is bilateral and present above & below the waist
Fibromyalgia psych associations
May be associated with sleep
deprivation & depression
FM tx
Refer to a rheumatologist for
evaluation & treatment
s/s of FM
dental related?
Tingling, numbness, tightness, stiffness & swelling may affect the jaw. Dizziness is common.
Toothache & gingival pain occur commonly in fibromyalgia patients.
Fibromyalgia Medications Effective:
Lyrica (pregabalin)
Antidepressants (i.e. amitriptyline)
Savelle (SNRI)
Fibromyalgia Medications Minimally Effective:
NSAIDs
Opioids
Benzodiazepines
Fibromyalgia Conservative Treatment
1. Sleep?
2. therapy?
3. activity?
- Sleep hygiene- keep bedtime & awakening time the same each day; only
sleep while in bed- no TV or computers; rule out obstructive sleep apnea - Cognitive behavioral therapy to cope with pain
- Light impact aerobic activity (i.e. swimming, beginner’s aerobic class)
- Strength training with light weights
MOVEMENT DISORDERS: OROFACIAL DYSKINESIA
INVOLVES?
MAY involve what?
MAY cause injury to?
More common with?
Patient must provide a history of?
Cranial nerve examination is positive for?
INVOLVES INVOLUNTARY, CHOREATIC MOVEMENTS
MAY involve the face, lips, and/or the jaw.
MAY cause traumatic injury to the tongue or oral mucosa
More common with advancing age, use of neuroleptic medications and/or traumatic brain injury, psychiatric or certain neurologic disorders
Patient must provide a history of dyskinesia involving the orofacial region, history and examination is positive for myalgia and arthralgia that worsens with episodes of dyskinesia
Cranial nerve examination is positive for sensory &/or motor nerve conduction deficit (i.e. Trigeminal nerve)
MOVEMENT DISORDERS: OROFACIAL DYSTONIA
INVOLVES ?
MAY involve what tissues?
pain? impacts?
Traumatic injury to?
More common with certain?
Patient must provide a history of ?
Cranial nerve examination is positive for?
Intramuscular EMG?
INVOLVES INVOLUNTARY, EXCESSIVE SUSTAINED MUSCLE CONTRACTIONS
MAY involve the face, lips, tongue and/or the jaw disappearing during SLEEP.
Painful & can make opening/closing of mouth difficult; can impair speech, swallowing & chewing
Traumatic injury to the brain/head/neck can trigger transient or permanent dystonia involving the MASTICATORY MUSCLES
More common with certain neurologic disorders (i.e. Parkinson’s Disease), or adverse reaction to medications especially neuroleptic medications
Patient must provide a history of dystonia involving the orofacial region, history and examination is positive for myalgia and arthralgia that worsens with episodes of dystonia
Cranial nerve examination is positive for sensory &/or motor nerve conduction deficit (i.e. Trigeminal nerve, Facial nerve)
Intramuscular EMG confirms the dystonia diagnosis
Treatment of Masticatory Muscle Pain
Goals of Treatment:
1. Decrease?
2. Increase?
3. Resumption of?
4. Onabotulinum A injections for?
- Decrease pain
- Increase range of motion
- Resumption of normal daily activities (i.e. talking, eating a normal diet)
- Onabotulinum A injections for Oromandibular Dyskenesia and Dystonias
